 Okay, thank you very much for that introduction and that wonderful pronunciation of my last name The I'd like to this afternoon. I was given the task of speaking about Yogurt in weight management, but I'm going to stop by speaking about dairy in weight management for two reasons first of most importantly In my opinion, and I think it's been true this morning in other presentations it's critical to consider any potential effect of yogurt in the context of it's of the effects of Dairy itself when we're focusing on the yogurt We we need to try to determine if the effect of yogurt is just a consequence of the fact that it's dairy or If there's if there are effects that are unique to yogurt and I think that's been brought up in many of the sessions earlier today The second reason is that I was I'm going to talk a little bit about about dairy as a whole Is that I was asked to speak for 20 minutes and if I was going to speak on yogurt in weight? It would be about five-minute talk, so So let me start with my by financial disclosures I am currently receiving Grant support from Dan and to examine the relationship between dairy and health and I'm also on Dan and scientific advisory board All right, so let me start the examination of dairy and weight with this meta-analysis of Chen and colleagues this figure is from the paper summarizes the results of 29 separate trials and that examined dairy is an intervention in in the effect of dairy interventions on weight change and they've presented these Different these slides give me these data separately for studies that have Used energy restriction and those without energy restriction Their findings overall suggests that the studies the effect of dairy without energy restriction There really is no effect that they see in this summary But there is a suggestion of a modest effect in those studies that that that have used energy restriction so I this afternoon I really don't want to debate the findings of this rather meta-analysis of dairy and weight because I could do that I have some some few issues with this meta-analysis some other meta-analysis But again the reason I wanted to show this to you is to first of all remind you that there are potential effects of dairy on weight independent perhaps independent of yogurt and Also to show you that these 29 trials Provide little evidence to enlighten us about yogurt and weight actually among these 29 trials There were only two that considered yogurt as a is a separate intervention And those were both energy studies of energy restriction one of those trials was that of Thomas and colleagues and the other the second was Zemmel and You can see from this slide that the effect the effects in both of these trials were quite similar the the in the Thomas intervention. They saw about an effective yogurt of about 1.4 kilograms less weight gain or a pretty great weight loss and In the also in the Zemmel trial. They saw a greater weight loss of about 1.6 Kilograms, so I just very briefly want to go into these two studies in a little bit greater detail now the purpose of the Thomas a Study was to examine the effect of yogurt some supplementation on changes in body composition in overweight women engaged in Resist in a resistance training program. It was a relatively small study. They had 29 individuals 15 of Them who were assigned to the to the yogurt intervention in 14 to an isochloric sucrose beverage This was consumed before and after exercise For 16 weeks and this was in combination with a 250 kilocalorie per day energy deficit As I showed you on the last slide the difference between the two treatments was about 1.4 kilograms with a greater loss of weight in the yogurt room the Zemmel study was designed to Examine whether yogurt would accelerate weight and fat loss induced by caloric restriction and healthy obese adults Again a relatively small study. I don't know the numbers here. I think there are 34 individuals in this study subjects would Were prescribed the 500 kilocalorie per day deficit diet for 12 weeks then randomized either to a controlled diet Providing at most one serving of dairy products of zero one serving per day of dairy products Or a diet containing three a daily six ounce servings of fat free yogurt Now this slide shows the results of the Zemmel study and they observed About a 30% reduction in Weight over the course of the the 12 weeks They saw about a 60% reduction In a greater greater reduction in in fat and body fat and they also observed about a 15% Reduction in the in the amount of lean mass loss. So there was they had a greater Loss of weight greater loss of body weight and less loss of lean mass So just summarizing I mean this is that's all we have there so summarizing these two trials I mean both of these studies are consistent with an effect of of of yogurt on body weight yogurt a dairy Because there was no Non-yoga dairy intervention for the comparison though We can't attribute the observed effects to yogurt itself and that's why I think one of the limitations of In something we have to consider in any interventions that we do if we're interested in looking Specifically yogurt. We have to have non-yoga dairy controls In addition to the the the intervention studies relating Yogurt to or dairy to to weight there was also a systematic review of there's a large literature on on observational evidence and This slide summarizes a systematic review of the prospective cohort studies These investigators identified 19 prospective cohorts studies of dairy intake and weight change Eight of these studies showed a protective Association of dairy against increasing weight gain one study reported a significant protective association But this was only seen among men who would initially overweight Seven reported no association with dairy intake one reported increased weight gain with increasing dairy intake Two reported either a decreased or increased weight gain depending on the specific dairy foods Only three of these studies in the review considered yogurt as a separate food item However, subsequent to the publication of this paper in 2011 There was an additional study published in 2012 that also considered yogurt separately Okay in this slide I've attempted to try to summarize these for studies side-by-side But before going into detail or describing studies I want to note that these these four studies gave minimal detail about Really about the examination of yogurt in these cohorts Because none of these styles studies were designed to look at yogurt and weight two of the studies the cardiac study in the supermax study the purpose was look at overall dairy and The other two studies looked not only at dairy, but at multiple food groups Okay, so the the first study listed here the 2002 study of Pereira was performed using data from overweight young adult participants Using who were sampled from four large u.s. Metropolitan areas as you can see But over half of this sample was black They did not report mean be am I in this study, but the prevalence of Obesity among the white participants was about 45 percent and about 66 percent among the black participants They assessed diet in this in this study using a 28-day food frequency questionnaire quite extensive food frequency They assesses a baseline and then it's year seven of the study No yogurt intake in this study was very low the median intake among the black participants was Basically zero servings per week whereas the median intake among white participants was 0.3 servings per week The study of drapeau and colleagues examined food groups and weight change in a small cohort of parents and adult children from Quebec yogurt intake was assessed at baseline and At the at the end of the study six years into the study using three-day diet records now one thing about the the use of three-day, I mean we this study may have had Misrepresented or underestimated the the intake of yogurt in these in this population Because of the episodic nature of yogurt intake a three-day diet record might not be the ideal means to capture that intake and again This study did not report What the yogurt intake was in this sample The Sufimax trial is a large antioxidant vitamin and mineral intervention study that was that recruited participants from all over France In this study they collected dietary data using computerized 24-hour recalls To in order to be included in the study Investigators required that the participants had to have at least six computerized 24 recalls within the first 18 months of follow-up now this in this study obviously it's a little bit different being in France than it then in North American populations and here rather than reporting servings of yogurt in terms of Servings per week they do it in terms of servings per day So the mean intake among men in this population was about a half a serving of yogurt per day Whereas the mean intake among women was about two-thirds of a serving of yogurt per day and the the final Prospective observational study was that of most the firing and colleagues published in 2011 and They used data on a hundred more than hundred and twenty thousand men and women from the three Harvard health Professionals cohorts the nurses health nurses health study that nurses health study to and health professionals follow-up study They at baseline they excluded any one who Was considered obese or had any chronic disease These investigators measured diet using food for extra questionnaires and over in this a specific study They required three to five food for extra questionnaires to be included in the study and again this This paper did not report the usual yogurt intake in this population Okay, so this slide presents the results from these four studies In the cardiac study the investigators reported that the ten-year obesity incidence Was cut in half essentially the odds ratio of point four seven per each serving of yogurt per day The Quebec family study investigators did not See any association with weight change they looked at change in yogurt over time relative to weight change So they did not see any association between the change in yogurt consumption between baseline and follow-up relative to the change in Weight between baseline and follow-up They did however report that yogurt was positive that change in yogurt was positively associated with the change in waste circumference over the course of the study with about a point for Centimeters additional waste change per serving For over the six years of follow-up Now the Suvi max trial investigators Stratified the sample not only by sex, but also by weight status and they observed that in Normal weight men there was no association However in overweight men they observed that high yogurt consumers gained about 55 percent less weight over the course of the study Compared to the low yogurt consumers and they saw a similar result for waste circumference However in the women everything was a little bit different First of all they observed the normal weight women that the high yogurt consumers gained about 53 percent more weight and they observed no association between the yogurt consumption and Weight change in the overweight women and they observed no associations between Yogurt and change in waste circumference And finally the the study from the health professionals cohorts Which is out already been shown earlier this morning? Showed that the four-year weight gain Was about point just just to clarify they're looking at weight gain So so everybody gained weight but but over four years the weight gain in these cohorts was about point eight two pounds less For every serving of yogurt consumed and they observe similar associations and all three cohorts Okay, so Given the limited data specific to yogurt intake and weight management Weight management my colleagues and I felt that it would be valuable to revisit the relationship between dairy and weight With a focus on yogurt We felt that the Framingham heart study offspring cohort would be an ideal Setting for examining the relationship between yogurt and weight Because of the availability of multiple measures of dietary intake and the use of clinic-based weight and waste circumference measurements and a long follow-up period in this case we follow up for over 15 years So we had a sample of about 3,440 participants with almost 12,000 observations over this over a follow-up period of about 12.9 years the data we used were based on for Forgive me and yeah and for Exams which which were collected Between it's data from the four exams which were collected between 1991 and 2008 we assessed a Diet using the Harvard fruit fritter questionnaire we Based yogurt on the average intakes at the start and the end of each exam interval we we we actually Stylish study very closely to that of the most safarian study the differences They had equal exam periods all of their exam periods before your exam periods the Framingham They rate could range from two and a half years up to about five years. So to to deal with that We again calculated the weight change within each exam interval, but we annualized the The weight change so it's looking at change per year so we could account for the varying length and in of the exam intervals For those of you who care we use the repeated measures regression approach to examine these associations We adjusted for a number of different factors has been mentioned this morning I mean yogurt consumers do differ substantially from non-yuga consumers So in any of this type of observational work, we have to be really careful and try to account for those differences so we Adjusted for sex and also for a number of variables as time-dependent variables and those included age smoking status physical activity blood pressure diabetes status cholesterol lowering medication use blood lipids total energy intake and Diacquality quality and we assess diet quality using the dietary guidelines adherence index score We also Tested for interactions between dairy consumption in both sex and BMI, but none of those interactions were statistically significant For the purpose of the the presentation today, we categorized Total dairy we categorized dairy as total dairy which included high-fat dairy and low-fat dairy yogurt and then to try to capture The the you know the difference between yogurt and and total dairy we also examined total dairy excluding yogurt These are the participant characteristics for the cohort at the fifth examination Because you'll notice here that fifth examination only had 3,099 subjects There's about 300 subjects who we didn't have data for it the fifth examination We still included in the in the analysis. We just started them at a later interval. So we still included them in the follow-up The average age at the fifth examination for these individuals was about 54 years about 46% of the samples was men They were on average quite overweight About 19 was 19% was a regular cigarette smokers on average These individuals consumed about two servings of dairy per day and that was Pretty much equally split between high-fat and low-fat dairy and on average this population consumed just a little under one serving of yogurt per day These are the results from showing annual changing weight by total dairy consumption and as you can see Comparing those who consumed three or more servings per day relatives to those who consume less than a serving per day We saw about a 50% reduction in weight gain over the course of the follow-up This slide shows the relation that same relationship by yogurt intake and again. We can see comparing this in case in this case we're comparing three greater equal to three servings per week Not day to those with a less than one serving per week and again be comparing those two categories We still see about a 50% reduction in the rate of weight gain I Think it's important now to note that that of two things first of all we didn't see any reduction in in the rate of weight gain and We saw it only among those who were consuming three or more servings per day Per week of yogurt, but I think more importantly or more interestingly is the fact that we're seeing the same reduction In weight over follow-up with three servings per week as we did with total dairy Where we were looking at three servings per day up to three servings per day This slide shows annual change in weight by total dairy consumption excluding yogurt and As you can see here that the association has been attenuated The the the difference now between the highest and lowest categories of dairy consumption is only 30% rather than 50% and the the P for trend is no longer statistically significant this slide shows the annual change in waste circumference by total dairy and Again, you see a nice trend across the categories of total dairy consumption and the difference between these groups is about 15% between the highest and lowest categories is about 15% and Regarding the the annual change in waste circumference Again with yogurt in this in this case with yogurt. We see actually a slightly stronger Association the difference now between the highest and lowest categories is about 20% a little bit greater than that which we saw for total dairy and Then again when we look at total dairy excluding yogurt again, we see an attenuation of the association with total dairy Still seeing the trend, but it's no longer statistically significant So in summary, you know yogurt consumption Appears to be associated with smaller gains and weight and waste circumference I think the support from our study and also from that of mozifarian But these associations may not be unique to yogurt as Other dairy products were also related to changes in weight and waste of conference I'll be it in the weaker manner and in terms of the gaps in the literature what we really know and don't know I mean this although there's a large body of data relating dairy intake to weight management We know very little about the relationship Specific relationship between yogurt and weight management So I think we have a fairly large gap and a knowledge regarding the potential benefits of yogurt. Thank you We have time for Several quick questions and quick answers Andrew Prentice again. I'm sorry if I seem a Comudgian, but I'm still deeply troubled by this issue of residual confounding So in your analysis you put in a lot of covariates But as I read it, none of those covariates could capture Health behaviors that are likely to be heavily related to yogurt consumption So the first thing I want to do is to make that as a really important research agenda point I mean to you know, if you were if you were nastier than me you could say this data means nothing I don't say that But the issue is that so the question is do you have any other measures in the framing and that you could put in? I mean, I would put it I would want to put in, you know, IQ professional occupation a level of education weight of the spouse There's a whole load of things that we could put in there Attitudes to healthy body weight that we could put in there which would help us to tease out these very important associations We do I mean first of all to address the question We I mean we feel one of the most important potential confounds First of all to say residual confounding is always a concern and you know with with Adjusting for any of these factors we choose these to try to tease out You know alternate explanations for what we're seeing You know our feeling for example is that is that? You know diet and diet quality. We know that the people who consume yogurt have better diets And so that was a big focus of what we did we looked not in the results. I presented here It looked at it overall diet quality, but we also adjusted for every different food group That we could look at so we spent a lot of time trying to get this to go away by Adjusting for other dietary factors for other nutrients associated with things like that So so that that really had a minimal Impact on the association was seeing even with the residual confounding we would assume that when we start adjusting for overall diet quality That we'd see some reduction some attenuation, but the attenuation was minimal In terms of other lifestyle factors, you know one of the important ones in in terms of weight would be physical activity We adjusted physical activity, but my concern with that measure is is that we don't measure framing ham and none of us in Epidemiology really can get a good grasp I think on on Energy expenditures, so so although we measure we measure and control for it. I think we have a lot of potential residual confounding For physical activity some of the other measures you mentioned we don't have in framing ham We don't have any attitudinal questions about weight That there are questions They do collect information. I don't believe on income, but they do on on education And I'm I don't recall whether we have we've actually looked at it as I look at my postdoc who's done the analysis Whether we've actually adjusted for education is but I don't think we have Can I just make it clear that I'm not trying to undermine the data at all. I'm trying to do the reverse I'm trying to strengthen it So please don't let me give the impression that I'm anti this data or in any way Anti-yoga quite the reverse is the case. I'm trying to strengthen our case No, and I and I agree. I think we have to any and any observational analysis. We have to try to shoot it down ourselves We have to try to look to see What alternative hypotheses they might be to explain these these such as change differences in lifestyle And there's someone mentioned this morning wearing sandals, you know, I think you did, you know We didn't have sandals, but but a sandal use but but if you know if we had that I mean we try to use that as hypothesis try to try to see if we can explain away what we've seen with the Alternative hypothesis, so I think it's very important what you the point to raise it are critical and and And and I think we should do more. I mean whenever we see an association We should do everything as investigators everything We can't to try to to shoot that down ourselves before we send it out and have other people shoot it down for us Sorry, just a follow-up answer to that question because I Did the analysis so I thought that I might answer that specific question So actually in terms of the can residual confounding factors We did we did two sets of analysis So the first analysis as Paul show here we adjusted for the DJI score Which is an index score to assess the participants adherence to the diet? 2005 dietary guidelines so in that DJI score we captured each item recommendations made in the dietary guidelines and By using that score we were able to capture the overall diet quality of the participants. So in that sense we the results shown here on the the association between yoga and the smaller way again is we we are Confidence that it it can it's kind of independent of the participants overall diet quality because we adjusted for that and also we we did another sensitivity analysis by adjusting for Individual full groups rather than the overall diet quality DJI score and in that sensitivity analysis Oh, we observe no very similar association as you just saw here so I think and also for like Education and physical activity and smoking status we adjusted for all of all of those Information but in terms of the income I don't If I don't recall wrong, we don't have that information on hand So we were not able to take that into account But yeah, that that's a very good point that we should definitely look at and thank you Last question a quick one very nice presentation Paul I was wondering in in those subjects that gained less weight after taking yogurt I've you had the ability of the The opportunity actually to look at the fat distribution Because we know that those that are gonna lose more of the visceral fat will have a better Cardiometabolic profile. I don't know if you have imaging data, but the other way to do it would be to measure blood triglycerides Which along with Ways to conference and the BMI can give you a good index about which one in these courts actually lost more visceral fat Yeah, no we we Apart from Ways to conference, which which doesn't necessarily correlate that well But but we we do we have imaging but only at one exam We don't have it longitudinally so we really couldn't assess that we do I believe have triglycerides So it all of the exam so that's something we could probably look at. Thanks Thank you very much